Care home deaths show system failures

Fatal cases in assisted living raise questions about family choices, state oversight

Alice Frazier, 103, rests between exercises in the lobby of Emeritus Carlsbad Wednesday. For many of the seniors living at the Emeritus Carlsbad facility, exercise and other activities like puzzles and bingo are part of their daily activity options.
— Peggy Peattie

Alice Frazier, 103, rests between exercises in the lobby of Emeritus Carlsbad Wednesday. For many of the seniors living at the Emeritus Carlsbad facility, exercise and other activities like puzzles and bingo are part of their daily activity options.
— Peggy Peattie

Hundreds of seniors in San Diego County have suffered broken bones, deadly bed sores, sexual assaults and other injuries at assisted living homes that promised them care and safety in their waning years, state regulatory records show.

For many, poor care hastened their deaths. At least 27 San Diego County seniors have died since 2008 from injuries and neglect suffered in the facilities.

Judith Kohl (center) lived at Alpine Charlie’s in Alpine, where she wandered out of the house fell in a ditch and broke her leg and lay there until someone found her and took her to the sheriff’s office. She later died.— Peggy Peattie

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Judith Kohl (center) lived at Alpine Charlie’s in Alpine, where she wandered out of the house fell in a ditch and broke her leg and lay there until someone found her and took her to the sheriff’s office. She later died.
— Peggy Peattie

Their deaths reveal critical failures — both public and private — in a system responsible for assuring that seniors can live in affordable, homelike settings rather than in expensive, institutional nursing facilities.

Their stories were not made public by state regulators, prosecutors or police, an ongoing six-month investigation by U-T San Diego and the CHCF Center for Health Reporting found.

For some of the seniors who died, the state agency charged with protecting them never investigated or penalized their caregivers, according to a review of thousands of records from the California Department of Social Services, or DSS.

Out of 18 deaths that the state did investigate and judge preventable, 12 cases were subject to a fine. It was $150, the maximum allowed by law. The locations cited in state documents include:

• Wesley Palms in San Diego, where a man died after he fell and spent two days on the floor of his room, undetected, bruised and soiled with feces.

• Merrill Gardens in Oceanside, where the staff showering and caring for a resident overlooked six deepening bedsores on his hip, heel, coccyx and testicles in the time before he died.

• Mission Home IV in San Diego, which failed to act after finding a woman on the floor at 7 a.m. “with wet clothing and bedding, soiled underpants and unable to articulate,” records state. She died, too.

Representatives of Wesley Palms and Merrill Gardens said they took steps to reduce the risk of such problems recurring. A Mission Home representative said the state sanction was about a paperwork problem, not poor care.

The series

The deaths are a tiny fraction among the population of about 14,500 residents living in 640 homes in San Diego County, many of them providing a quality environment. But they raise critical questions about how families pick facilities for their loved ones and how the state monitors their care.

Wesley Palms’ executive director, Ben Geske, said he often hears from residents who enjoy living there.

“I think we have a staff that cares about our residents, that forms personal relationships with our residents,” Geske said. “Is it 100 percent? No, it’s not. But I think we do a pretty darned good job.”

Makeshift barricade

Hilma Johnson, like many others with dementia, climbed out of bed at night and wandered the halls.

So workers at the small Alpine assisted living home where she lived built a makeshift barricade around her bed with a desk, a walker, a wicker seat and a large rocking chair.

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Johnson, 93, tiny but determined, tried scaling the barricade one night in April 2009. She fell, smashed her head on the desk and broke her hip. The staff did not call her family or 911 but laid her back in bed.

She didn’t see a doctor for four days. Six weeks later, she was dead.

The suspicious deaths of Johnson and 26 others represent a partial count, due to the difficulty of identifying such cases in public files.

State regulators say they cannot determine how many seniors have died from problems in those homes because an antiquated computer system is incapable of tracking the deaths.

Reporters counted deaths for this story by reviewing the agency’s paper documents as well as records from the county medical examiner, the courts and a local consumer group. The tally includes only deaths that government records describe as caused by poor care.

There may be many more. The county medical examiner investigates certain accidental deaths, including those in assisted living homes. At least 196 deaths in such homes since 2009 have been reviewed by San Diego County’s medical examiner, according to reporters’ analysis of that department’s records.

The examiner is not required to notify the state Department of Social Services of its findings, and the department’s inspectors do not monitor its reports, meaning that suspicious deaths may fall through the cracks, with a resident’s survivors not even knowing the facts.

The U-T investigation with the center, based at the University of Southern California, found:

• The top fine is $150 if the state concludes a resident’s death was caused or hastened by the facility’s lack of proper care. By contrast, the top state fine is $100,000 when poor oversight leads to the death of a patient in a nursing home.

• State law requires that assisted living residences be inspected every five years, although almost every other state inspects such homes once a year. California Department of Social Services officials say they are shortening inspection requirements and increasing visits to once every 30 months.

• California is one of only two states nationwide where a social services agency oversees assisted living facilities. Elsewhere, 37 states assign that job to their health departments, according to a 2013 survey by the National Center for Assisted Living.

• In the past five years, the number of complaints alleging poor care in the homes climbed 13 percent, to nearly 3,000, while the number of penalties issued fell 30 percent, to 6,787.

California Department of Social Services senior deputy director Pat Leary called the safety of the homes “an area of great concern.”

In an hourlong interview in July, she laid out a portrait of an agency committed to protecting residents despite budget cuts and outmoded technology.

“This is a very, very important issue,” she said. “It’s a licensing responsibility that we do take very seriously.”

State law requires facilities to notify the Department of Social Services of all deaths or face penalties, and law enforcement officials often provide reports, Leary said. The agency also receives complaints from residents, their relatives, facility staff members and others caring for residents, she said.

Asked why the agency did not investigate some suspicious deaths and other problems at the homes — known as residential care facilities for the elderly, or RCFEs — Leary said inspectors might never have heard about them.

“When we receive a complaint, we will go out and do a visit and follow up,” Leary said. “The frustration is that I think you’ll find, in some of the cases you looked at, we never had the opportunity to take the action.”

Screaming in pain

Four days after Hilma Johnson fell from the barricade, her granddaughter visited her at Alpine Charlie’s, the six-bed home where she lived. Johnson was screaming in pain when her granddaughter tried moving her into her car to go see her doctor, according to interviews and court records.

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Not only was her hip broken, but doctors at Scripps Mercy Hospital discovered that she was severely dehydrated, with an advanced urinary tract infection and large yellow bruises on her arms, hip, shin and head, court records state.

Johnson’s granddaughter, Heather Harpole of San Diego, expected the state to shut down the home in rural Alpine, 31 miles east of downtown San Diego.

Instead, state Department of Social Services inspectors found the facts surrounding Johnson’s death inconclusive. So Harpole went to court and won a $4.7 million judgment. Lisa C. Clark, Alpine Charlie’s operator, declared bankruptcy and never paid it. The home closed in 2012, according to the department’s records.

Clark declined to comment but said in a 2010 court document that she and the home did nothing negligent in Johnson’s death.

“Why should this woman not be held accountable for her actions?” Harpole said in a June interview.

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Harpole had experienced first hand the netherworld of assisted living in San Diego County, homes that many consumers view as health facilities.

Under California law, they’re not health facilities, but homes offering seniors assistance with daily tasks, such as bathing, eating and housekeeping. Some also care for residents with dementia, like Hilma Johnson, or those requiring hospice care.

Consumer advocates in California have long contended that seniors living in many assisted living homes are exposed to dangerous, sometimes lethal, conditions that the Department of Social Services frequently fails to monitor or correct.

Regulators and representatives of assisted living homes say such circumstances are the exception, not the rule. The majority of homes, they say, are safe and responsible.

Their reports on San Diego County homes, on file at the department’s office in Mission Valley, provide details of how some local seniors died.

Some tumbled from beds and chairs and were not found for days. Some bled to death. At least two residents, unnoticed, choked on food.

Inspectors discovered maggots in a resident’s wound at one home. They found ants swarming inside someone’s diapers at another. They found seniors sickened by highly contagious infections such as Clostridium difficile, a potentially deadly intestinal infection, or drugged on dangerously high doses of Valium and Xanax.

Some residents were raped or fondled by their caregivers. At a facility in Encinitas, a 2010 Department of Social Services report states, two female staff members would tease a male resident by clutching their breasts and asking the resident, “Do you want this?”

Living longer, growing sicker

A patchwork system ranging from six-bed bungalows and suburban split-levels to large facilities housing 300 or more residents makes up San Diego County’s assisted living community.

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These privately owned domiciles often prove a godsend for seniors who can no longer live on their own but find that, with some limited assistance, they can avoid nursing homes.

The assisted living homes of the late 20th century evoked images of rocking chairs on wide porches framed with hollyhocks, knitting groups and the occasional field trip to a casino or local shopping mall.

As seniors lived longer and grew sicker, they and their families began choosing the facilities over nursing homes, which seemed too institutional to many consumers.

Media accounts of nursing home scandals helped feed the trend, some experts said. Marketers began promoting assisted living homes as cheaper, more appealing alternatives.

The result was a spurt in California, where the number of licensed assisted living homes has nearly doubled in the past 20 years, from 4,075 in 1990 to 7,695 in 2012, according to California Department of Social Services statistics. Most are for-profit facilities, some owned by national chains.

“Assisted living grew out of consumer demand for more residential settings,” said Sally Michael, president of the California Assisted Living Association, which represents homes throughout California.

“Baby boomers are getting older,” Johnson said. “They may be looking for a place.”

Residents are older, averaging nearly 87 today, up from 83 in 1998, said David Kyllo, executive director of the National Center for Assisted Living. The center is part of the American Health Care Association, which represents nearly 11,000 assisted living homes, nursing homes and other facilities.

Both the assisted living industry and some long-term care experts say many residents don’t want the round-the-clock oversight offered by nursing homes.

David Virden, a spokesman for Emeritus Senior Living, which operates more than 450 homes nationwide, with 85 in California, wrote in a July 22 email, “Part of the attraction of assisted living is that it provides a high degree of independence and autonomy, allowing people to age with dignity and reside in their apartments with limited or no restrictions as much as possible.”

Critics say that as assisted living residences increasingly accept older, medically challenged seniors, the California Department of Social Services appears ill-prepared to address their needs.

And because these homes are regulated by a social services agency and not a public health department, some departmental employees may lack the formal medical training to properly investigate incidents.

“The training standards are deplorable. To care for residents, you’re qualified if you have 10 hours of initial training,” Carlson said.

Critics of the California Department of Social Services — which also licenses more than 70,000 other facilities, including adoption agencies and day care centers — are especially incensed by the small size and scant impact of penalties.

“If you kill a California condor, it’s $25,000,” said Chris Murphy, a San Diego advocate for the elderly. “If you kill a resident, it’s 150 bucks.”

Joel R. Bryant, a San Diego-based attorney, also questions the size of the fines.

“A $150 fine has no deterrent effect,” said Bryant, who has represented residents and families in lawsuits against homes since 1995. “The fine has to be such that it can motivate for-profit entities — that it’s in their best interest to follow the rules.”

He added, “These rules we’re talking about are for the care of the elderly. One hundred and fifty dollars — it’s an insult to how society views the care and safety of the elderly.”

At the department, Leary responded that she does not view the fine as a deterrent.

“That $150 is set by law. It’s a statutory maximum,” she said. The power to increase that fine, she added, rests with the state Legislature.

Today, the real deterrents are the penalties her agency can impose on a problem facility, such as placing a home on probation, prompting more frequent inspections, Leary said.

“Those are the things that certainly have more of an economic impact than the existing $150 fine,” she said.

Four of the facilities in San Diego County are on probation: Brookdale Place of San Marcos; Country Gardens in Fallbrook; Cabanas Adult Care Home in San Diego; and Cabanas Care Home in Oceanside.

To learn what led to the probation, consumers can search individual paper files in the California Department of Social Services office. Even then, they may not find documents that spell out the facilities’ errors leading to probationary penalties, because some files are missing a variety of reports.

Consumer Advocates for RCFE Reform, founded by Murphy after her mother’s death in an assisted living home, has also posted thousands of inspection reports of local homes that consumers can pore through for a small fee at rcfereform.org.

‘Everything is dark’

State health officials announce publicly when they find significant problems at nursing homes and hospitals. And they serve up hefty penalties.

For instance, in June, health officials handed out fines totaling $275,000 after the deaths of four patients in four nursing facilities statewide. They held an Aug. 15 news conference to announce fines from $50,000 to $100,000 they issued to 10 hospitals statewide for problems with patient care, including a $75,000 fine to Sharp Memorial Hospital in San Diego.

The Department of Social Services is less transparent.

It does not publicly announce its assisted living investigations or fines, even for cases in which residents died due to neglect or poor care. Nor does it post records online, as Medicare does for hospitals and nursing homes.

One prosecutor troubled by the setup is Deputy District Attorney Paul Greenwood, the man in charge of prosecuting elder abuse cases for the County of San Diego.

Frustrated that the department wasn’t notifying him of such cases, he contacted top administrators in July 2012 to ask that he receive all violation reports as they’re issued. He now reviews them regularly.

“This type of crime is only going to get more widespread in the months and years to come,” Greenwood said. “We have a duty to clean up the RCFE industry, to highlight the good ones and target the bad ones.”

‘What’s more important?’

The Department of Social Services experienced severe budget cuts in 2003, and changed its regular inspections for all facilities from once per year to every five years.

The new schedule concerns industry and consumer advocates. In fact, two major assisted living trade groups in California support more frequent inspector visits.

“It would really help if they were able to go out once a year like they did 10 years ago. The visits weren’t so dramatic,” said Johnson at the Community Residential Care Association of California.

Today, the agency does random visits annually of 30 percent of assisted living homes, and more visits may be ordered to respond to complaints, Leary said. Even so, she said, the standard visits are only required to be conducted every five years, and that much time can elapse between inspections.

With many public documents hard to find, and little guidance from the California Department of Social Services, a family seeking a home for a loved one may flounder at judging the quality of a facility.

Betty Watson and Richard Blaisdell have been outspoken in their criticism of the state’s oversight of assisted living facilities after their experience with the now-shuttered Alpine Charlie’s in Alpine. Watson’s sister, Judith Kohl, was a resident until she wandered out of an unlocked door, fell and broke her hip. Peggie Peattie • U-T

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Betty Watson and Richard Blaisdell have been outspoken in their criticism of the state’s oversight of assisted living facilities after their experience with the now-shuttered Alpine Charlie’s in Alpine. Watson’s sister, Judith Kohl, was a resident until she wandered out of an unlocked door, fell and broke her hip. Peggie Peattie • U-T

“How are we to know? It’s all kept in secret,” said Richard Blaisdell, a critic of the state’s policies who with his wife, Betty Watson, lives on a ranch called Rattlesnake Acres in Pine Valley, 46 miles east of San Diego.

They had no idea they could view a home’s inspection records at the Mission Valley office.

They turned to a placement agency suggested by a doctor to find a home for Watson’s older sister, Judith Kohl, who they said was suffering from mild dementia.

The agency recommended Alpine Charlie’s, the same six-bed home where Hilma Johnson fell in 2009 while climbing the barricade of furniture. Kohl moved into Johnson’s old bedroom, members of both families said.

Kohl, too, was a wanderer, and one day in early 2010, she walked past an unlocked gate, down a nearby road, fell in a ditch and broke her hip. She was rescued by a passer-by who took her to the sheriff’s station. She underwent surgery and recovered.

Like Johnson’s family, Kohl’s family sued Alpine Charlie’s. They won $500,000 in a court judgment. Like Johnson’s family, they didn’t collect.

Blaisdell is still angered by the darkness he glimpsed while caring for his sister-in-law. The owners of poorly run homes, he said, are shirking their responsibility to the elderly, and so is the agency that licenses them.

“If they were handling explosives that could kill people, there would be standards,” Blaisdell said. “If they were saving people’s money in the banking industry, there would be standards.

“What’s more important? These people are you and me. These people need to be supported, and they’re being sold short.”